Delayed ART initiation in “Test and Treat era” and its associated factors among adults receiving antiretroviral therapy at public health institutions in Northwest Ethiopia: A multicenter cross-sectional study

Background Antiretroviral therapy (ART) has shown promising effects on the reduction of new HIV infection as well as HIV-related morbidity and mortality. In order to boost the effect of ART on ending HIV epidemics by 2030, the World Health Organization (WHO) indeed introduced a universal test and treat strategy in 2015 that recommends rapid (within seven days) initiation of ART for all HIV-positive patients. However, in low-income countries, a substantial number of HIV-positive patients were not enrolled in time, and information on delayed ART initiation status in Ethiopia is limited. Method A multicenter cross-sectional study was conducted on 400 HIV-positive adults receiving ART at public health institutions in Bahir Dar city, Northwest Ethiopia. A structured checklist was used to extract data from the patient’s medical record. Data was entered into Epi-data version 4.6 and exported to SPSS version 26 for further analysis. Both simple and multivariable binary logistic regressions were executed, and variables with a p-value < 0.05 in the final model were considered significant predictors of delayed ART initiation. Results The magnitude of delayed ART initiation was 39% (95% CI: 34%–44%). Being male [Adjusted odds ratio(AOR) = 1.99, 95%CI:1.3–3.2], having opportunistic infections (OIs) [AOR = 2.50, 95%CI:1.4–4.6], having other chronic diseases [AOR = 3.70,95%CI:1.7–8.3], substance abuse [AOR = 3.79, 95%CI: 1.9–7.4], having ambulatory functional status [AOR = 5.38, 95%CI: 1.4–9.6] and didn’t have other HIV-positive family member [AOR = 1.85, 95%CI: 1.2–2.9] increases the odds of delayed ART initiation. Conclusion and recommendation The burden of delayed ART initiation is found to be high. The presence of OIs and other chronic problems, substance abuse, ambulatory functional status, being male, and not having other HIV-positive family members were identified as significant predictors of delayed ART initiation. Special emphasis needs to be considered for those individuals with the identified risk factors.

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The data underlying the results presented in the study are available from (include the name of the third party and contact information or URL). This text is appropriate if the data are owned by a third party and authors do not have permission to share the data.    city is the area of the earliest ART service center in Amhara regional state. It is located at 565 km 69 Northwest of Addis Ababa, the capital city of Ethiopia. Currently, the city has around 11 (two 70 hospitals and nine health center) functional ART centers. According to the report of the Amhara   The main response /dependent variable for this study is the occurrence of delayed ART initiation. information. In addition the consistency of the checklist against the patient chart was verified by 115 taking 10 charts and necessary modification was done accordingly.

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Data processing and analysis procedures 117 The data was initially coded, entered into Epi data version 4.6.0.0 and simultaneously exported to  ART initiation (Fig 1). However, ART initiation time was greatly varied among different 3.79 or more times at risk to be initiated early on ART than their counterparts (3.79, 95%CI 1.9 179 7.4). The odds of late ART initiation among ambulatory patients is nearly 5 times (5.38, 95%CI 180 1.4 -9.6) than bedridden HIV positive patients (Table 3). 1-Reference category, * statistically significant at bi-variable with 5% level of significance, ** statistically significant at multivariable with 5% level of significance, CI-confidence interval, N.B-Since we used backward likelihood ratio to select candidate variables of delayed ART initiation, we didn't display the AOR value for variables with P-value of greater than 0.1

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Hosmer and Lomeshow goodness of test for multi logistic regression revealed that the model 186 constituting such variables is good to predict the outcome variable i.e delayed ART initiation ( P-187 value =0.639) . Indeed the discrimination power of the model was checked by receiver operating 188 curve and the area under the curve value (AOC value = 0.744%) illustrated that the model is 189 excellent to discriminate individuals with delayed ART initiation with their counterparts (Fig 2). Africa (27), and Zimbabwe (28). On the other hand, this finding is slightly lower than a study 202 conducted in Taiwan(4) which might be due to a difference in socioeconomic and educational 203 status between the two countries.

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In the current study male HIV-positive individuals has higher odds of being delayed for ART 205 initiation than their counterparts. This finding is congruent with previous studies conducted at 206 Nekemte (12), and South Africa(10). The possible elucidation for this might be the fact that 207 women's decision to immediately seek ART will be highly influenced by physician's counseling 208 than males. Furthermore, if the women were found to be HIV positive during pregnancy, lactating, 209 labor and delivery, she will be highly reinforced to begin ART at the spot or as early as possible.  The risk of delayed ART initiation is nearly four times among HIV-positive individuals with 221 chronic problems than their counterparts. This finding is consistent with previous systematic 222 review and meta-analysis studies conducted before the current test and treat era in Ethiopia (19).

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The possible justification for this might be also due to the fear of pill burden, drug-drug All relevant data's for this study presented within the manuscript.

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All authors have declared that they have no conflicting interests.  We would like to express our deepest gratitude to Bahirdar University, College of Medicine and

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Health Science for letting us to conduct this research and timely availing ethical clearance. Next,

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we also advance our profound thanks to staffs working at ART clinic, card room and administration The authors did not receive any specific fund for this project.